4VA/DoD Essentials for Posttraumatic Stress Disorder: Provider Tool

IntroductionThis pamphlet is a step-by-step tool created to assist health care providers with care of patients experiencing post-traumatic stress conditions. Post-traumatic stress (PTS) refers to a spectrum of conditions including combat operational stress reaction (COSR), acute stress reaction (ASR), acute stress disorder (ASD), and acute and chronic posttraumatic stress disorder (PTSD). Primary care and non-behavioral health providers may see patients who have any one of these conditions. The diagram below depicts the general timeline of these conditions.

Acute PTSD

2 days 1 month 3 months

TRAUMA

Chronic PTSD

ASR/COSR ASD

Step 4: ReferPTSD and co-occurring conditions should be treated concurrently through an integrated treatment approach, which considers patient preferences, provider experience, severity of conditions and the availability of resources.

Provider Actions for Referral:Primary care providers can use the following checklist when considering a referral to specialty care.

q Identify patient preferences.

q Identify potential barriers and facilitators (e.g., travel vouchers to overcome geographical barriers).

q Engage with family, caregivers and/or significant others.

q Perform a “warm handoff” (e.g., in-person or telephone clinical transfer of patient from one provider to the next, ideally involving patient).

q Assess need for telemental health options.

q Assess need for community and web-based referrals (e.g., Military OneSource, vet center, afterdeployment.org).

Barriers to Seeking Behavioral Health Treatment

Hopelessness or Cynicism AvoidancePatients may be skeptical about the effectiveness of

behavioral health treatment and may believe that problems will resolve on their own

Patients may want to avoid reminders of the event or may have had a negative experience in behavioral

health treatment in the past

EMPHASIZE the success of evidence-based treatments REMIND patients that their safety and comfort will always come first

ShamePatients may feel shame about the trauma,

their role in the trauma or their reaction

Denial

Patients may be in denial that symptoms are problematic

COMFORT and NORMALIZE the patient’s feelings EDUCATE about the negative results of leaving PTSD untreated

StigmaPatients may feel accepting treatment is a weakness,

especially in military populations, and may fear behavioral health treatment will negatively impact their military career

Access

Patients may be distant from services or have competing priorities

REASSURE that many recover without harm to their career DISCUSS available resources

For more information on prescribing medication please see the Posttraumatic Stress Disorder Pocket Guide.

The VA/DoD Clinical Practice Guideline for the Management of Post-traumatic Stress can be found at: healthquality.va.gov/Post_Traumatic_Stress_Disorder_PTSD.asp or https://www.qmo.amedd.army.mil/ptsd/ptsd.html

Department of Veterans Affairs and Department of Defense employees who use this information are responsible for considering all applicable regulations and policies throughout the course of care and patient education.

2

3

Step 2: Set Expectations for RecoveryProvide patients with educational information that encourages positive ways of coping, describes simple strategies to resolve or cope with developing symptoms and problems, and sets expectations for mastery and/or recovery. The process of care for PTSD must include a definitive diagnosis before initiating treatment. The primary care provider may decide to refer to specialty care options at any point depending on comfort and experience with treating PTSD.

Step 3: Educate About Evidence-Based PsychotherapiesStrongly recommend to patients who are diagnosed with PTSD that they follow through with referral to evidenced-based trauma-focused psychotherapy treatments that include components of exposure, cognitive restructuring and/or stress inoculation training. Examples of such treatment methods include:

1 A.

Step 1: Screen and AssessAll new patients should be screened for symptoms of PTSD using a validated tool initially, and then on an annual ba-sis, or more frequently if clinically indicated. The Primary Care PTSD Screen (PC-PTSD), below, is a four-item screen designed for use in primary care and other health care settings. The PC-PTSD is not intended for use in specialty care clinics. Additional tools that may be used are the PTSD Brief Screen, Short Screening Scale for DSM-IV-TR PTSD or the PTSD Checklist (PCL). A positive screen on a provider or self-report measure suggests PTSD, but does not constitute a definite DSM-IV-TR diagnosis.

Discuss Treatment Options for PTSD with Patient if Indicated

Primary Care-based Options § Psychoeducation § Symptom-driven medication (e.g., sleep, pain)

§ Pharmacotherapy (e.g., SSRI, SNRI)

§ Symptom monitoring § Treatment of co-occurring behavioral health (e.g., depression, substance abuse) and physical health concerns

§ Brief intervention for substance abuse

Specialty Behavioral Health Options § Further assessment (Consider PCL-C/CAPS/SCID)

§ Trauma-focused psychotherapy intervention that includes components of exposure and/or cognitive restructuring, or stress inoculation training

§ Pharmacotherapy (e.g., SSRI, SNRI) § Family therapy/group therapy

Prolonged exposure therapy (PE) is an exposure-based cognitive behavioral therapy and involves:

Eye movement desensitization and reprocessing (EMDR) therapy is designed to alleviate the distress associated with traumatic memories and involves:

Cognitive processing therapy (CPT) is a cognitive restructuring-based

cognitive behavioral therapy and involves:

Stress inoculation training (SIT) is a set of skills for anxiety managment:

§ Psychoeducation § Deep relaxation techniques § Imaginal exposure that will involve repeated retelling of the trauma focused on thoughts and feelings

§ In-vivo exposure to situations that a patient avoids because they evoke trauma reminders

§ Identification of a target memory, image and belief about the traumatic event

§ Desensitization and reprocessing to focus on mental images while performing saccadic eye movements

§ Reinforcement of positive thoughts and images

§ Psychoeducation § Identification of cognitive distortions about the event § Recognizing the relationships between thoughts and feelings § Writing a detailed daily account of the trauma § Challenging assumptions and cognitive distortions § Focusing on themes of safety, trust, power, esteem and intimacy

§ Relaxation training to help control fear and anxiety § Breathing retraining on slow abdominal breathing to help the patient relax

§ Positive thinking to help replace negative thoughts with positive ones

§ Assertiveness training to help express emotions appropriately § Imaginal and behavioral practice of better stress coping skills

Primary Care PTSD Screen (PC-PTSD)Provider Question: If Patient’s Response is YES, Provider Response:

“In your life, have you ever had any experience that was so frightening, horrible or upsetting that in the past month you… “You said that you… “Other examples…

1. Have had nightmares about it or thought about it when you did not want to?”

…have nightmares about the event or think about it when you don’t want to. This may be a symptom of PTSD called re-experiencing.”

...of re-experiencing symptoms are: intrusive thoughts, flashbacks, or having strong feelings or sensations when you think about or are reminded of the event.”

2. Tried hard not to think about it or went out of your way to avoid situations that reminded you of it?”

...try hard not to think about the event or go out of your away to avoid situations that remind you of it. This may be a symptom of PTSD called avoidance.”

...of avoidance are: not wanting to be in large crowds, not wanting to watch the news, or not wanting to be in any other situations or with people that remind you of your experience.”

3. Were constantly on guard, watchful or easily startled?” ...are often on guard, watchful or easily startled. This may be a symptom of PTSD called hyperarousal.”

...of hyperarousal are: having sleep problems, being irritable or having sudden outbursts of anger, or being easily startled.”

4. Felt numb or detached from others, activities or your surroundings?”

...feel numb or detached from others, activities or your surroundings. This may be a symptom of PTSD called emotional numbing.”

...of emotional numbing are: diminished ability to have loving feelings, withdrawing from family and friends, and not enjoying the things you used to enjoy.”

AssessPC-PTSD Screen Results PTSD Status Provider Action

Patient answers YES to at least two of the questions

POSITIVE Assess symptoms further (e.g., time of onset, frequency, course, severity, level of distress, degree of functional impairment)

Patient answers YES to one or fewer questions

NEGATIVE Monitor symptoms

Some organizations use a cutoff score of two, and some use a cutoff score of three for a “positive screen.” Follow your organization’s guidance.

After Screening and Feedback, Follow Up with Patient

Communicate to the patient that he/she has options and:

§ Adopt a non-judgmental, empathetic approach § Elicit patient preferences and listen reflectively § Emphasize patient responsibility and autonomy in decision-making

§ Elicit pros, cons, potential barriers and facilitators to treatment options

§ Support self-efficacy

Check for Co-occurring Conditions

PTSD frequently occurs with other conditions. Identification of co-occurring conditions helps to guide follow-up treatment or referral

If patient endorses symptoms of PTSD, ask about: − Depression (PHQ-2 and PHQ-9) − Sleep disturbances − Substance abuse or dependence − Traumatic brain injury − Generalized anxiety or panic disorder − Suicidality

B.A.

B.

C.